Custom Blend Intake Form
This form is for general wellness support and is not intended to diagnose or treat any condition. Your information is kept private and used only to create your custom blend.
Name
First Name
Last Name
Email
example@example.com
Phone Number (optional, in case email issues come up)
Please enter a valid phone number.
Format: (000) 000-0000.
What brings you here today? Tell me what you're hoping this tea can support - examples include hormone balance, energy, digestion, sleep, immune health, stress, skin, emotional support, or something else.
Are there any specific concerns or symptoms you'd like me to know about?
Do you prefer:
Caffeine-free only
Low caffeine is okay
No preference
Are there any herbs you already love or would like included if possible? (List specific herbs or flavors - sweet, floral, earthy, minty, etc.)
Are there any herbs, tastes, or textures you strongly dislike or want to avoid? (List anything I should leave out)
Do you have any known allergies, sensitivities, or medications I should be aware of? (This is pertinent information that helps me ensure safe herb choices)
Are you on any medications? (This is important for me to formulate a safe and supportive formula for you, as certain medications can have herbal contraindications)
Do you have any pre-existing health conditions? (Again, this is important so I can be sure to formulate with herbs that are safe and supportive for your body)
Are you pregnant or breastfeeding? (This is pertinent information that helps me ensure safe herb choices)
Pregnant
Breast-feeding
Neither
Type option 4
Do you have a preferred size for your tea blend? (Optional - Most blends are 2-3 oz. I'll suggest the best size for your needs.)
Would you like to request rush blending (if available)?
Yes, if possible
No, I'm in no rush
Maybe - tell me more
Anything else I should know before formulating your blend?
Submit
Should be Empty: